Download The Psychological Effects of Intifada Al Aqsa: Acute

Isr J Psychiatry Relat Sci Vol 42 No. 2 (2005) 96–105
The Psychological Effects of Intifada Al Aqsa: Acute Stress
Disorder and Distress in Palestinian-Israeli Students
Naiera Musallam, BA, Karni Ginzburg, PhD, Liat Lev-Shalem, BA, and Zahava Solomon, PhD
Adler Research Center, School of Social Work, Tel Aviv University, Ramat Aviv, Israel
.
Abstract: The study assesses the effects of exposure to nationality-related and personal stressful events, threat appraisal
and coping strategies on level of distress of Palestinian Israeli students. One hundred forty-eight Palestinian Israeli students filled out a battery of questionnaires that tapped their exposure to stressful life events, terrorism and political related violence, their primary and secondary appraisals, and coping strategies. Level of distress was evaluated by (1)
acute stress disorder, and (2) psychiatric symptomatology. Results reveal relatively low exposure to terrorism-related
traumatic events, yet considerable exposure (35.8 %) to nationality-related stressful events during the last two years.
Twenty-five percent of the students suffered from acute stress disorder, and their levels of psychiatric symptomatology
exceeded norms for the general population. Primary appraisal processes and emotion-focused coping strategies made
unique contribution to the respondents’ level of (1) acute stress disorder and (2) psychiatric symptomatology. The implications of these findings are discussed.
Introduction
The latest peak in the long-term Israeli-Palestinian
conflict, Intifada Al Aqsa, the Palestinian uprising,
commenced in September 2000 and is still going on
at the time of writing. During the current Intifada,
Palestinians set off bombs in Israeli shopping malls,
buses, restaurants and other crowded places, killing
and maiming many Israeli citizens, including Palestinians who reside in Israel. Israeli forces entered
Palestinian cities, put the Palestinian people under
siege, demolished houses, and bombed residential
areas. By the end of September 2003, more than
2,200 Palestinians and 790 Israelis had been killed
(1). No resolution of the conflict in the near future is
in sight.
About a million Palestinians, those who remained within the borders of Israel in 1948 and became citizens after the establishment of the State,
now live in Israel as an ethnic minority. They find
themselves in a difficult and complicated reality.
They perceive themselves primarily as Palestinians.
Many have first- and second-degree relatives in the
occupied territories. Most identify nationally and
emotionally with the Palestinian people in the occupied lands. A survey of 1,202 Palestinian Israelis conducted by Ganim and Smooha (2) shows a high level
of identification with the Intifada and the struggle of
the Palestinian nation. Similarly, findings of a survey
conducted by Ben Meir (3) show a soaring rise in the
percentage of Palestinian Israelis who identify as Palestinians, from 46.4% in 1996 to 74% in 2000, and a
plummeting decline in the percentage that identify
as Israelis, from 38.4% to 11% during the same time
period. Many Palestinian Israelis experience a conflict of identities — on one hand, they feel geographically connected to their current homes within the
State of Israel, but on the other hand they nationally
and emotionally identify with the Palestinian population in Gaza and the West Bank.
For a variety of reasons, the Palestinian minority
in Israel may be regarded as a high-risk group for the
detrimental psychological effects of the current wave
of terror. Like all Israelis, the Palestinian citizens of
the country are potential victims of terror attacks as
they ride the buses, attend university, and otherwise
go about their daily lives, and feel much the same
fears and apprehensions as the Jewish population. At
the same time, however, they also fear being targets
of hostile and angry actions by Jews should they be
caught in the vicinity of a terror attack.
In addition to these terror related stresses, Palestinian Israelis experience other concurrent stressors
stemming from being a minority group. Many per-
Address for Correspondence: Professor Zahava Solomon, Adler Research Center, School of Social Work, Tel Aviv University, Ramat Aviv, Tel Aviv 69978, Israel. E-mail: [email protected]
NAIERA MUSALLAM ET AL.
ceive themselves as suffering from systematic and institutionalized economic, educational and cultural
discrimination. Such social inequity has been identified as a risk factor for psychological distress, feelings of worthlessness, helplessness, powerlessness,
and of being looked down on, as well as sadness and
fear (4).
The current Intifada further compounds these
stressors. Most Palestinian Israelis have never taken
a direct or active part in the conflict, though many
have been involved in supplying humanitarian aid to
the Palestinians in the occupied territories during Israeli military actions, sieges and curfews there. Their
identification with the Palestinian people, however,
is a major source of stress. As Montiel (5) points out,
the effects of political traumatic stress can extend beyond individuals within the geographical boundaries of the traumatic episode and negatively affect
other individuals who identify with the political positions of the victims. This is particularly likely to
happen as the victims and the bystanders have much
in common.
In addition, Palestinian Israelis, like other Israelis, are exposed to considerable life events and economic difficulties, which were consistently shown to
have pathogenic effects, particularly on individuals
who are concurrently troubled (6).
Stress appraisal, coping and responses to
stress
It is well known that extremely stressful or traumatic
events can evoke symptoms of distress in many people, expressed by a variety of manifestations, including acute and post-traumatic stress disorders,
anxiety and depression (e.g., 7). Yet considerable individual variability in response to such events has
also been noted. Wortman and Silver (8) point out
that emotional, cognitive and behavioral responses
vary even within homogeneous groups of individuals who have been exposed to similar stressors.
Some of this variability may be accounted for by
the individuals’ appraisal and coping strategies. According to Lazarus and Folkman (9), the response to
stress is determined by a two-stage process of appraisal. During the primary appraisal, the individual
evaluates the level of threat, and during the secondary, the individual assesses his or her capability to
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deal with this stress. Various studies suggest that
these appraisal processes are implicated in the genesis of stress reactions (10).
While the appraisal processes refer to the individual’s perception of the event and himself, coping
strategies describe his or her actual reactions to the
stress. That is, they are defined as the cognitions and
behaviors one uses to reduce the detrimental effects
of the stressors (9). Among these strategies are problem-focused strategies aimed to change the stressful
situation (e.g., planning, taking direct action, screening out other activities, or searching for instrumental
support), and emotion-focused responses aimed to
deal with the emotions caused by the stressors (e.g.,
denial, mental disengagement, positive reinterpretation of the event, and seeking for emotional social
support) (11).
Although coping strategies are relatively stable
over time, and the tendency to employ a certain
strategy often reflects a disposition (12), still, their
relative use may vary along time and situations.
While the significant role of coping strategies in adjustment to stress is well recognized, there is less
agreement regarding the effectiveness of each of
these strategies in specific situations. That is, various
studies suggest that denial, avoidance and mental
disengagement are non-adaptive strategies, and are
associated with distress following various traumatic
events (e.g., 13). Others, however, pointed to the effectiveness of denial and emotional avoidance (e.g.,
14).
Moreover, most of the studies that examined both
appraisal processes and coping strategies studied
their impact on the adjustment of survivors after the
termination of a defined, usually discrete, stressful
event (e.g., 15). Only a limited number of studies examined the role of these variables in prolonged
events that consist of repeated stressors, such as war
(e.g., 16). Moreover, their implications in the adjustment of individuals in the course of an ongoing violent conflict, with no end in sight, were not studied
to the best of our knowledge.
The current study aims to assess the effects of exposure to nationality-related and personal stressful
events, threat appraisal, coping strategies, on distress
of Palestinian Israeli students’ as reflected in (1) rate
of acute stress disorder and (2) psychiatric
symptomatology.
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THE PSYCHOLOGICAL EFFECTS OF INTIFADA AL AQSA
Method
Subjects
The sample consisted of 148 Palestinian Israeli (71
males and 67 females) who reside in the student dormitories at Tel Aviv University. Response rate was
93% (11 refused), and among the reasons given for
refusal were lack of free time to complete the questionnaire. Subjects’ ages ranged from 19 to 27
(M=21.1, SD=1.41). Ninety students (68%) were
Moslems; 43 (32%) were Christians. Forty-eight percent defined themselves as secular; 48% defined
themselves as traditional; and only 4% defined
themselves as religious.
Measures
Exposure to stressful events
Three indices examined exposure to stressful events:
A. The subjects’ history of personal stressful life
events was queried via a self-report questionnaire listing 11 events (e.g., assault; major illness;
17). Items were derived from previous studies
that assessed life events and were deemed adequate for this age group. Subjects were asked to
indicate whether they had experienced each
event in the last year. Based on their responses,
they were classified into two groups: Those
who had experienced at least one personal life
event during the previous year and those who
had not.
B. To examine exposure to “nationality-related”
stressful events, subjects were asked whether
during the last two years (since the beginning of
the Intifada) they had suffered as a direct consequence of being part of a national minority.
C. Exposure to terror attack was examined by three
questions: subjects were asked whether during
the last two years (since the beginning of the Intifada) (1) they had been exposed to a terror attack, (2) someone in their family had been
exposed to a terror attack, or (3) somebody else
they knew had been exposed to a terror attack.
Appraisal
Subjects’ appraisal of stressful experiences and selfefficacy was examined by a modified seven-item
scale based on the Solomon and Prager (17) measure
that has been repeatedly used in trauma research in
Israel with various groups (18, 19). Modification was
done with the assistance of Palestinian-Israeli students who are — like the subjects themselves — students at the Tel Aviv University. Varimax Rotated
Factor Analysis yielded three factors that explained
76% of the appraisal’s variance. The first factor, nationality-related threat, consisted of three items (“To
what extent are your Palestinian relatives in danger,”
“To what extent is your future as a Palestinian under
a threat,” and “To what extent have you suffer as a direct consequence of belonging to a national minority”), and explained 27% of the appraisal’s variance.
The second factor, terror-related perceived self-efficacy consisted of two items (“To what extent do you
think you will know what to do under a terror attack,” and “To what extent do you think you will
function effectively under a terror attack”), and explained 25% of the variance of appraisal. The third
factor, terror-related threat, consisted of two items
(“To what extent do you think your life is in danger,”
and “To what extent do you think your family is in
danger”), and added 24% to the explained variance
of the appraisal. Based on his or her responses,
each subject received three scores, one for each factor.
Stanford Acute Stress Reaction Questionnaire
This self-report questionnaire (20) consists of 30
items, describing dissociative, intrusive, avoidant,
and hyperarousal symptoms. Respondents are asked
to rate, on a 6-point Likert scale (1=not at all; 6=to a
great extent) the extent to which they suffer from
each of the symptoms.
Based on the DSM-IV (18), subjects are identified as suffering from acute stress disorder (ASD) according to the following criteria: (a) having
experienced a traumatic event in the previous month
and endorsement of (b) at least three dissociative
symptoms, (c) at least one intrusive symptom, (d) at
least one avoidant symptom, and (e) at least one
hyperarousal symptom. Following Harvey and
Bryant (20), subjects who endorse the required number of symptoms from three of the symptom categories (criteria b-e) are designated as having subclinical
ASD. In addition, this scale assesses the severity of
ASD, calculated as the mean of the total score. This
questionnaire has been used to assess ASD in various
NAIERA MUSALLAM ET AL.
populations, and has high test-retest reliability. The
Cronbach alpha for the current sample was high
(0.93), indicating high internal consistency.
Brief Symptom Inventory (BSI)
The BSI (21) is a 53-item self-report symptom inventory designed to assess psychological symptoms. Per
each item, respondents are asked to rate the degree
to which they experience the symptom on a 5-point
scale of distress ranging from “not at all” to “extremely.” The items reflect nine symptom categories:
somatization, obsessive compulsiveness, interpersonal sensitivity, depression, anxiety, hostility, public
anxiety, paranoid ideation and psychoticism. The inventory also enables calculating a global index of distress: the General Severity Index (GSI) that assesses
the overall severity of the psychiatric symptomatology.
Cronbach alphas for the nine symptom categories range from a low of 0.71 on psychoticism to a
high of 0.85 on depression. The GSI’s Cronbach
alpha in the current sample was high (0.96), indicating high internal consistency.
COPE (11) which we used to examine coping, is a
60-item scale designed to assess 15 coping strategies.
Subjects are asked to indicate on a 4-point Likert
scale (1= “I usually don’t do this at all”; 4 = “I usually
do this a lot”) the extent to which they used each.
The Cronbach alphas for the 15 scales ranged from
0.37 for mental disengagement to 0.93 for use of religion (11). The Cronbach alphas for the current sample were satisfactory, ranging between 0.48-0.88.
Procedure
All Palestinian Israeli students residing at the dorms
were approached by one of the researchers (NM) and
were asked to participate in the study. The questionnaires were handed out personally to each potential
subject at her or his room at the dorms of Tel Aviv
University. Subjects were asked to fill in the questionnaire at a time convenient for them, and they
were collected from them a week later. The aims of
the research were described, and confidentiality was
assured.
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Results
Exposure to stressful events
Sixty-six subjects (45%) experienced at least one personal stressful life event during the recent year. With
regard to the nationality-related events, 35.8% of the
participants (N=53) reported that in the two years
preceding the study they had suffered as a direct consequence of being part of a national minority. Finally,
none of the participants had been personally exposed to a terror attack.
Based on their exposure to personal stressful life
events and nationality-related events, subjects were
classified into four groups of exposure: 41 subjects
(29%) experienced only personal life events, 30
(21%) experienced only nationality-related events,
23 (16%) experienced both personal and nationalityrelated events, and 49 (34%) had not experienced either personal or nationality-related events.
Exposure to stressful events and stress
appraisal
To examine the relationship between stressful events
and an individual’s appraisal, we conducted
MANOVA with terror-related threat, national-related threat, and terror-related self-efficacy as dependant variables, and exposure as the independent
variable. The MANOVA yielded a significant effect
(F (9,331)=1.88; p<0.05). Three ANOVAs revealed
that the source of this effect was associated with national-related threat (F (3,142)=4.24; p<0.01).
Duncan contrasts indicated that those who were exposed to nationality-related event or to both personal and nationality-related events reported higher
levels of threat than those who were not exposed to
either personal or nationality-related events (see
Table 1). Exposure was not related to either terrorrelated threat or terror-related efficacy.
Exposure to stressful events and coping
To examine the relationship between exposure
to stressful events and coping strategies, we conducted a series of ANOVAs. These analyses indicated that the exposure groups differed in their use of
two coping strategies: seeking emotional support
(F (3,141)=3.06), and focusing on and venting emotions (F (3,141)=3.06). Duncan contrasts indicated
that those who experienced personal stressful
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THE PSYCHOLOGICAL EFFECTS OF INTIFADA AL AQSA
events, and those who experienced both personal
and nationality-related events tended to seek more
emotional support than those who were not exposed
to either personal or nationality-related event. In addition, those who experienced both personal and nationality-related events tended to use more venting
strategies than those who were not exposed to either
personal or nationality-related events.
The exposure groups did not differ in their use of
the other coping mechanisms.
Exposure to stressful events and distress
Acute Stress Disorder (ASD): A quarter of the participants (25.2%; N=36) met DSM-IV criteria for
acute stress disorder. Another 23.1% (N=33) met the
criteria for partial ASD.
Table 1. Means and standard deviations of stress appraisal, coping strategies and distress measures according to exposure
group
1. Personal
event
2.Nationalityrelated event
M
SD
M
SD
3. Both
Personal and
NationalityRelated events
M
SD
Terror-related threat
1.34
0.87
1.75
1.08
1.67
Terror-related PSE
1.33
0.90
1.63
1.14
Nationality-related threat
2.94
0.86
3.23
Positive reinterpretation and growth
1.77
0.72
Active coping
1.42
Planning
Seeking of emotional support
4. None
M
SD
1.11
1.24
0.87
1.48
1.17
1.26
1.10
0.78
3.36
0.84
2.66
1.02
1.93
0.71
1.94
0.78
1.70
0.74
0.92
1.62
0.97
1.45
1.04
1.21
0.88
1.54
0.76
1.81
0.97
1.74
0.66
1.35
0.75
1.88
0.74
1.83
0.99
1.95
0.85
1.43
0.87
Seeking of instrumental support for reason 1.59
0.84
1.68
0.71
1.61
0.73
1.26
0.73
Suppressing competing activities
1.37
0.76
1.34
0.84
1.31
0.72
1.15
0.86
Religion
1.99
1.26
1.56
1.22
1.69
1.36
1.58
1.16
Acceptance
1.83
0.76
1.98
0.88
1.81
0.88
1.68
0.93
Mental disengagement
1.01
0.72
1.20
0.81
1.14
0.81
1.02
0.85
venting of emotions
1.92
0.73
2.01
0.83
2.22
0.82
1.61
0.96
Behavioral disengagement
0.94
0.80
1.01
0.73
0.94
0.84
1.04
0.90
Denial
0.62
0.64
0.90
0.89
0.44
0.59
0.66
0.61
Restraint coping
1.34
0.81
1.33
0.78
1.23
0.71
1.23
0.76
Alcohol/drug use
0.79
0.54
0.99
0.66
0.97
0.54
0.41
0.59
Humor
0.87
0.88
1.21
1.31
1.15
1.35
1.12
1.19
ASD
1.22
0.71
1.49
1.08
1.74
0.84
1.14
0.80
3>1,4
GSI
0.95
0.40
1.18
0.65
1.47
0.59
0.90
0.56
3>1,2,4
Stress Appraisal
2,3>4
Coping strategies
1,3>4
3>4
Distress
2>4
PSE = Perceived self efficacy
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NAIERA MUSALLAM ET AL.
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
OBS= obsessive compulsive
PAR= paranoid identity
HOS=hostility
SOM=somatization
DEP=depression
IS= interpersonal sensitivity
GSI
OBS
PAR
HOS
Research Sample
SOM
DEP
IS
ANX
College Students (USA)
PSYC PHOB
ANX=anxiety
PSYC=psychoticism
Adults (Israel)
Fig. 1. Means of intensity of psychiatric symptoms (BSI) for American students, Israeli Jewish adults, and our participants
Psychiatric symptomathology (BSI): In the absence of norms for Palestinian young adults and
other young adults in areas of political violence, the
participants’ mean psychiatric symptom levels were
compared with those of American college students
of the same age (22) and with those of Jewish Israeli
adults (23). The Jewish Israeli adults were assessed
between April and July of 2000, only several months
prior to the onset of the Al Aqsa Intifada. The three
sets of means are presented in Figure 1.
Z tests indicated that the BSI means of the study participants were significantly higher than those of the
American college students in all measures except interpersonal sensitivity (paranoid ideation z=7.89,
p<0.001; obsessive compulsive z=2.58, p<0.05; GSI
z=4.87, p<0.001; depression z=3.29, p<0.01;
somatization z=2.59, p<0.05; hostility z=6.45,
p<0.001; anxiety z=4.16, p<0.001; psychoticism
z=4.87, p<0.001; phobic anxiety z=10.33, p<0.001).
The participants’ BSI scores were also significantly
higher than those of the Jewish Israeli adults in all
the sub-categories but somatization (GSI z=5.44,
p<0.001; obsessive compulsive z=5.45, p<0.001;
paranoid ideation z=6.74, p<0.001; hostility z=7.17,
p<0.001; depression z=6.45, p<0.001; interpersonal
sensitivity z=2.72, p<0.05; anxiety z=4.01, p<0.001;
psychoticism z=6.02, p<0.001; phobic anxiety
z=8.03, p<0.001).
To examine the relationship between exposure to
stressful events and level of distress, we conducted
MANOVA with severity of ASD and the GSI index as
dependant variables, and exposure as the
independent variable. The MANOVA yielded a significant effect (F (6,278)=3.25; p<0.01). Two
ANOVAs, conducted to ascertain the source of this
effect, revealed that exposure was related to both
ASD (F (3,142)=3.19; p<0.05) and GSI (F
(3,142)=6.93; p<0.001). Duncan contrasts indicated
that those who were exposed to both personal and
nationality-related events reported on more severe
ASD than those who were exposed to personal
events and those who were not exposed to either personal or nationality-related events. In addition, those
who were exposed to both personal and nationalityrelated events reported on more severe GSI than the
other three groups, and those who were exposed to
national-related events had higher scores on the GSI
than those who were not exposed to either personal
or nationality-related events (see Table 1).
Exposure to stressful events, appraisal, coping
and distress
To examine the unique and cumulative contribution
of sociodemographic background, exposure to
stress, appraisal and coping strategies to the variance
of distress, we conducted two hierarchical stepwise
regressions, with ASD and GSI as the dependant
variables. In both regressions, the first step included
the sociodemographic variables (i.e., age, gender,
level of income and religious attitudes). The second
step included two exposure variables: exposure to
personal stressful event, and exposure to nationalityrelated stressful event. The third step included the
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THE PSYCHOLOGICAL EFFECTS OF INTIFADA AL AQSA
stress appraisal variables: terror-related threat, nationality-related threat, and terror-related self efficacy. The fourth variable included the 15 coping
mechanisms.
The first regression model explained 61% of the
variance of ASD (F (7,137)=31.03, p<0.001). None of
the sociodemographic variables included in the first
step entered the regression model. Of the exposure
variables, experiencing a nationality-related event
explained 5% of the variance of ASD. However, in the
next step, when the appraisal variables entered the
regression model, its contribution became insignificant. Terror-related threat contributed 23% to the
variance of ASD, and nationality-related threat
added 7%. Finally, four coping strategies entered the
regression model: mental disengagement which contributed 15% to the explained variance of ASD, venting added 6%, restraint 3%, and behavioral
disengagement 2%. The higher the perceived threat
(either terror-related or nationality-related), and the
stronger the tendency to employ mental disengagement, venting, restraint and behavioral disengagement, the more severe the level of ASD.
The second regression model, explained 35% of
the variance of GSI (F (5,137)=16.00; p<0.001).
Again, none of the sociodemographic variables included in the first step entered the regression model.
Of the exposure variables, experiencing a nationality-related event explained 10% of the variance of
GSI. Terror-related threat explained 12% to the variance of GSI, and nationality-related threat added 2%.
Finally, two coping strategies entered the regression
model: mental disengagement contributed 10% to
the explained variance of GSI, and venting added
1%. Exposure to nationality-related stressful event,
perceived threat (either terror-related or nationalityrelated), and the tendencies to employ mental disengagement and venting were related to higher levels of
psychiatric sympomatology, as measured by the
GSI.
Table 2. Regression models
ASD
First step
GSI
B
Adjusted R2
B
Adjusted R2
–
–
–
–
Second step
Nationality-related event
0.24**
5%
0.33***
10%
Third step
Nationality-related event
Terror-related threat
Nationality-related threat
0.13
0.50***
0.29***
23%
7%
0.25**
0.37***
0.17*
12%
2%
Fourth step
Nationality-related event
Terror-related threat
Nationality-related threat
Mental disengagement
Venting
Restraint
Behavioral disengagement
0.07
0.25***
0.15*
0.24***
0.25***
0.17**
0.15*
15%
6%
3%
2%
0.20**
0.24**
0.06
0.28***
0.18*
–
–
Total
61%
10%
1%
35%
NAIERA MUSALLAM ET AL.
Discussion
Twenty-five percent of the study participants were
found to meet the DSM-IV criteria for diagnosis of
acute stress disorder (ASD), while another 23% met
the criteria for sub-clinical ASD. In addition, the severity of psychiatric symptomatology of the respondents significantly exceeded the norms of both their
American counterparts (22) and Israeli Jewish adults
(23). These levels of distress seem extremely high in
light of the fact that the study participants reported
very low levels of exposure to the terror-related violence of the current Intifada in Israel. Indeed, much
lower levels of symptomatology were reported in a
recent study of a representative sample of the population of Israel, which included a proportionate
number of Palestinians. The latter study found that
while 16.4% of participants had been directly exposed to a terror attack and 37.4% had a family
member or friend who had been exposed, only one
reported symptoms consistent with the diagnosis of
ASD and only 9.4% reported symptoms consistent
with a diagnosis of PTSD (24). The distress levels
found in the current study are also high in comparison to the levels reported in the United States following the destruction of the World Trade Center. For
example, Galea et al. (25) found that 7.5% of the
Manhattan residents they assessed five to eight
weeks after the attack reported symptoms consistent
with a diagnosis of PTSD. A nationwide longitudinal
study of psychological responses to September 11
found that 17% of the U.S. population outside of
New York City reported symptoms of September 11related posttraumatic stress two months after the attack (26).
Several non-exclusive explanations may be offered for the high level of distress found among the
participants in this study. One is that it may stem
from the discrimination against Palestinians in Israeli society. This understanding is supported by the
findings that while the students’ distress, as reflected
in the outcome variables, was not significantly associated with their exposure to general life events, it
was associated with their experience of stressful
events related to their being Palestinians. This explanation is consistent with Butts’ (27) suggestion that
the social discrimination and hostility encountered
by minorities is a major source of distress, and with
103
other findings showing a close link between minority
status and PTSD (e.g., 28).
Another possibility is that the distress of the
study participants stemmed from the emotional
identification of the Palestinian citizens of Israel
with the Palestinians in the occupied territories. Witnessing the suffering of the Palestinians in the occupied territories, among whom many of the students
had relatives, is a source of great pain for them, made
all the worse by their not being able to help them in
any substantial way. Witnessing the suffering of significant others may also be a source of secondary
traumatization. According to Figley (29), secondary
traumatization results from close awareness of
trauma experienced by others, particularly individuals with whom one identifies or maintains meaningful relationships. This identification process may
also be related to Palestinian Israelis’ sense of collectivism. In a study conducted by Oyserman (30), Palestinian Israeli students reported higher levels of
collectivism than their Jewish counterparts, and
were more likely to generate identities focused on
national-religious-ethnic groups. Finally, in this respect it is also worth noting that exposure to the
media may also be a source of psychological distress.
Exposure to television coverage of terror events was
found in recent studies (e.g., 31) to be correlated
with posttraumatic symptomatology.
Yet a third possibility is that the high level of distress reflects a cultural reporting bias. Several studies
have demonstrated some reporting biases in various
populations. For example, Lee et al. (32) found that
higher rates of somatization are more prevalent
among individuals in non-Western cultures. Accordingly, one might suggest that the high rates of distress
found in our subjects reflect this population’s tendency for a reporting bias.
Interestingly, the high distress levels found in the
current study were much higher than those reported
in the Bleich et al. study (24), where no difference in
the distress levels of the Jewish and Palestinian subsamples were found. This suggests that something
beyond the terror, the discrimination that the students suffer as an Arab minority, and their emotional
identification with the Palestinians in the territories
may be augmenting their level of distress. It is possible that the Palestinians in the present study, who
were all students living in the student dorms, were in
104
THE PSYCHOLOGICAL EFFECTS OF INTIFADA AL AQSA
close and unavoidable proximity to the Jewish students at the dorms, who were hurting and angry and,
in some cases hostile, because of the terror. That is,
their living situation may have exposed them to
more averse conditions than that of the Palestinian
population as a whole. At the same time, being in the
dorms, they were far from their families and natural
support systems just when they needed them most.
Although being exposed to nationality-related
events was associated with severity of ASD, this association became insignificant once the threat appraisal measure was entered to the regression model.
Adjustment to stressful events depends not only on
objective factors, but also, and even more so, on the
individual’s subjective appraisal of the danger that
the event entails. This claim is supported by King et
al.’s (33) finding that perceived threat mediates the
association between objective level of exposure to
war stress and PTSD among veterans. Indeed, this
view was adopted by the DSM-IV (18) that established both objective and subjective criteria for identifying an event as traumatic: Objectively, the event
must involve actual or threatened death or serious
injury; subjectively, it must evoke intense fear, helplessness or horror.
Mental disengagement, venting, restraining and
behavioral disengagement were found to be nonadaptive coping strategies, whose use was associated
with higher levels of distress. These strategies, although they combine both approach and avoidance
tendencies, are all recognized as emotion-focused
coping strategies. These findings are consistent with
previous studies that linked pervasive use of emotion-focused coping strategies to the presence of
psychiatric symptomatology (34) and PTSD (14).
These findings should be examined in light of the
specific characteristics of the current sample. Our
study was conducted with subjects who are in the
midst of an ongoing stressful sequence of events,
whose resolution is unseen. A recent study of
Kanninen et al., that examined posttraumatic stress
symptoms among Palestinian former political prisoners pointed to the importance of the timing of assessment (35). The researchers found that the
pathogenic effect of emotion-focused coping was
mostly evident among prisoners who had only recently been released from prison, and almost disappeared in the long run. In light of these findings the
authors suggested that whereas emotion-focused
coping may be of little adaptive value in the longer
run, this tendency becomes more functional, as it
enables the individual to emotionally process his or
her experiences.
This study is timely and assesses the real time responses of a much-neglected but significant segment
of the Israeli population. Yet it has several limitations. One is that all the participants were Tel Aviv
University students who differ from the rest of the
Palestinian population in Israel in many ways, including, most saliently, in age, education and economic status. We must thus be careful in
generalizing the findings to the Palestinian population as a whole. Another limitation is methodological. Questionnaires were distributed in the dorms
and the participants were given a week to return
them; thus they could have consulted with each
other. We cannot be sure that we obtained their independent, spontaneous answers to all the questions.
Finally, the study does not enable us to determine
precisely which factors account for the participants’
particularly high levels of distress. Further study of
the population as a whole, using a more refined
method of information gathering and examining
more closely the relation between the outcome measures and possible contributory factors, is needed
and recommended. It is also advised that future
studies go beyond the methodology used here to include a comparison between Arabs and Jews, in regard to the psychological effects of the current
Intifada. It would be of great interest to assess the differences and the similarities between these two populations that differ from one another in both
national and religious aspects.
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